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Child Psychiatry

Child Psychiatry

Introduction:

Psychiatric disorders occur in childhood are different from those of adults, since they arise in complex and intimate family relationships, and are influenced by the stage of child development. Children also special present challenges for the evaluation and treatment. Psychiatric disorders present in childhood or adolescence are listed in Chart 1.

• Pervasive developmental disorders
• Specific developmental disorders
• Hyperkinetic disorders
• Conduct disorders
• Emotional disorders
• Psychiatric aspects of child abuse
• Elimination Disorders

  Table 1 Classification of psychiatric disorders of childhood and adolescence

Normal childhood development

Some of the characteristics of normal child development are shown in Table 2. It is essential to take into account the stage of development of the upper stage of the child for a psychiatric evaluation, and what is accepted as normal in an abnormal stage would in another.

Early childhood experiences play an important role in determining what type of person who becomes an adult. The role of parents in this is central. The child with the parents (or parent) who are loving and tolerant, however, able to set and enforce clear and reasonable limits likely develop high self-esteem, secure attachment to parents who provide a template for secure links with others in their future life. The theory of 'attachment' was first described by John Bowlby in the 1950s. It is derived from his study of young children separated from their mother at the hospital. attachment behavior begins around 7 months and is clinging and unwillingness to separate from the primary caregiver, usually the mother. It serves to strengthen the bond between mother and child and have the evolutionary function to ensure that the child is protected from predators. A securely attached child is able to use the mother as a secure base from which to explore the outside world can begin, and will also be able to cope well with short separations. If the attachment is unsafe, because the parent does not respond to the need for child care or exploitation, or is inconsistent, the child will have difficulties to explore and separate. This pattern of insecure attachment may persist throughout life, affecting relationships adult.

Assessment of Children

The way a psychiatric history is taken and examined under a dependent child age, confidence and language skills of children. Much of the story come from parents and children who are willing to leave their parents can be seen alone. Usually best to see adolescents alone and before their parents in order to establish a relationship of trust with them. The interview should take place in an atmosphere always relaxed and friendly, with toys and drawing materials for children under 10 years.

The history should include the following:

• The complaints described by both parent and child. It is important that lead to ask the child about the reason for consultation with softness, after winning their confidence and talk about neutral topics.
• Recent behavioral or emotional problems, including difficulties general health, mood, sleep, appetite, elimination, relationships, antisocial behavior, the life of fantasy and play, and behavior school.
• Personal history of pregnancy, birth, milestones (motor, speech, feeding, toilet training, behavior social), medical history, separation of parents, schools attended and progress in them.
• The structure and function construction of a genogram is often useful. The relationships between family members should be asked about, and interactions observed during the interview.
• Temperature footpaths traits such as activity level, regularity of the functions (sleep, intestines, eating), the ability to adapt to new circumstances, the willingness to approach people or new situations, quality and intensity of mood, quality of relationships within and outside the family, attention and persistence can be seen from a very early age.

A mental status examination of the child must be completed, although this will often rely on observation of behavior and play. The following should be considered:

• Future looks for any abnormality, bruises, cuts or scrapes and appropriateness of dress.
• Activity-level behavior, interactions with parents, motor function, attention and persistence with tasks.
• Talk-joint vocabulary and language use.
• The mood happy, elated, sad, depressed, anxious, hostile resentment.
• Thoughts of content of speech and life of fantasy, for example, ask for three magical wishes.

The assessment must be completed with a physical examination and talking to other informants involved with the child or the family as the family doctor, school teacher, educational psychologist, or social services. Investigations may be performed, usually intelligence tests and academic achievement tests such as standardized tests of reading.

Pervasive Developmental Disorder (Autism)

The Autism is a serious disorder that begins early and is manifested by the third birthday. It is characterized by an inability to establish social relationships, poor development of Language and resistance to change with limited and repetitive behaviors and interests. These children do not take into account or respond to the emotions of other people or social cues. They do not adapt their appropriate behavior to new environments, and are very restricted in their game, they rarely participate in simulation games. In general, choose the unusual soft toys and can not adhere to a particular object and refuse to be separated from it. Some will have very limited language skills, and abilities that are present usually not used in social conversation with others. Three-quarters have mental retardation important.

Autism has a prevalence 4 of 10,000 and is three times more common in boys than in girls. It is associated with brain damage in some cases genetic factors are thought to play an important role in the etiology. There is no specific treatment available. Families need a lot of support and advice, and behavioral problems can be controlled behavioral therapy. The result is generally poor, with only 15% is achieved independent functioning.

0-1 years

• Totally dependent
• Rapid development of motor – walk for a year
• Attachment behavior from 7 months

1-2 years

• Start talking
• Dry day
• Temper tantrums
• Separation Anxiety

2-5 years

• complex language skills
• Sociable
• Identity development sexual
• Identification with parents
• Since the formation of conscience
• Vivid fantasy life
• See themselves as the center of your world

5-10 years

• strong identity as a girl or a child
• Able to separate from the mother and
• Personality attributes acquired by the end of this period persist into adulthood

Adolescence

• Puberty – 11 to 13 years in girls and 13-17 years for males
• Establishing identity personal
• Establishment of autonomy from parents
• Learning to work and develop skills to become self-sufficient
• Relations with his bandmates are very important

Table 2 normal childhood development

Specific developmental disorders

In these disorders, specific skills such as reading, spelling, arithmetic skills, and language disturbed. The problems are present from early childhood. To make a diagnosis of specific developmental disorder, acquired brain trauma or disease should be excluded and the child must have had reasonable opportunity to acquire these skills at home or school. The causes of specific developmental disorders not known with certainty but is believed to result from alterations in cognitive processing. They are much more common in boys than girls.

disorder specific reading is particularly common with a prevalence of 5-10%. Typical distortions include reading problems or addition of words or parts of words, slow reading rate and loss of place in the text. Although the specific reading disorder is not due to inadequate schooling, Truancy is a common consequence of academic difficulties. Conduct disorder and reading disorder coexist specific frequency.

Disorder hyperkinetic

In the United States this is known as disorder and attention deficit hyperactivity disorder (ADHD). The main features the disorder are hyperactivity, restlessness, poor concentration, distractibility and impulsive behavior. These children are often clumsy, accident prone and end having problems with parents and teachers because they act without thinking. Other children often avoid and can become socially isolated.

Symptoms usually occur from an early age but is most commonly diagnosed in 6-9 years when there is a prevalence of about 8%. It is three times more common in boys than girls. Many causes have been suggested, from genetic factors to allergies and poor parenting. This is one of very few childhood psychiatric disorders treated with medications. stimulates the amphetamine-like are used, such as methylphenidate, which produce the paradoxical effects of reduced activity levels and improved care. This results in improved academic performance and developing friendships. Behavioral therapy, using a system of rewards for good behavior, also is useful for these children.

Hyperactivity disorder tends to improve with age, with only a quarter with continuing problems in adolescence. About half of these are still exhibiting some characteristics of the disorder in adulthood, and this often is expressed as behavioral conduct.

Disorder Behavior

The main features of conduct disorder are persistent antisocial behavior such as fighting, bullying, severe temper tantrums, damaging property, starting fires, theft, truancy, and persistent and defiant disobedience. The child's age must be taken into account, and mischief should not normally considered a sign of conduct disorder. One third of the cases have specific reading disorder, and there is considerable overlap with the disorder hyperactivity. behavioral disorders are common, present in at least 4% of children with a peak in the range of 12-16 years of age, and are three times more common in boys than girls.

There are two types of conduct disorder:

• Socialized conduct disorder. These children are able to make friends who also generally behave antisocial. Bad behavior is more obvious usually away from home. Relationships with adults can be good, although there are often difficulties with authority figures.
• Unsocialised conduct disorder. These children have no friends either because they have been rejected by their peers or because they deliberately choose to isolate themselves. Antisocial behavior occurs so alone. A certain degree of emotional disorder is is often also present in these children.

The causes of conduct disorders are a complex interaction between biological constitution the child, family influences and environmental factors as summersied Figure 1. The parenting style is thought to be important. conduct disorder are prone to develop if parents do not provide clear boundaries, control the behavior and administer discipline ineffective or inconsistent. Improved parenting skills is likely to improve behavior although other causative factors are present. Other treatment approaches include family therapy, behavioral therapy, school support and provision of alternative activities, peer group. The result is better for the group socialized. Two thirds of the group unsocialised will conduct persistent behavior in adulthood.

Emotional Disorders

Emotional disorders of childhood are characterized by anxiety and depression. They are present in 2-3% of children and exceptionally for children psychiatric disorders are more common in girls. They generally have a good prognosis.

Separation Anxiety Disorder

It is normal for toddlers and preschoolers to feel some anxiety about actual or threatened separation from their parents. In the anxiety disorder Separation anxiety is particularly severe or occurs in older children, and causes some problems in social functioning as the fight against child attends school. Symptoms include persistent concerns about the separation of the attachment figure (usually the mother) and great distress if forced to do so. Some refuse to go to sleep without his mother close and having nightmares about separation. overprotective parents is commonly present and other causes include child temperament and events stressful, particularly those concerning the separation, such as family breakdown, bereavement or illness

Anxiety disorders of childhood

Specific phobias about animals, the dark or strangers are normal in young children and rarely require treatment. disorder GAD can occur and is often charactersied by somatic symptoms, particularly abdominal pain.

Family influences

• martial disharmony
• absent parent
• parental violence, alcoholism, personality disorder
• poor parenting

Child

• genetic factors
• brain damage
• low IQ
• temperament

  

Environmental influences

• care institution
• school disciplinary code
• Peer influence group
• social deprivation

Behavior

Figure 1 The etiology of conduct disorder

Depressive illness

The symptoms of depressive illness are very similar in children in adults – the way of bass, anhedonia, sleep and appetite and depressive thoughts. Fleeting suicidal thoughts are common, but suicide is rare. Moderate to severe depressive illness are rarely pre-pubertal children, with a steady increase in incidence during adolescence. Causes of depression and its treatment are also similar to those of adults, although younger children seem to be less sensitive to antidepressant drugs adults, psychological treatment approaches are preferred.

School refusal

In rejecting the school the child refuses to attend school because of specific fears about the school, the trip to his or separation anxiety. This represents approximately 1% of all absences school and is much less common than truancy in which the child hides his absence from school and their parents. The characteristics of children with rejection of school compared with those usually steers in Table 1. school refusal should be handled by returning the child to school as soon as possible because avoidance is likely to raise anxiety. A re-grade as necessary, to support parents and children.

Child Abuse

Child abuse may take the form of neglect, emotional, physical or sexual abuse. It plays a role in causing psychiatric disorders in children can continue through to adulthood. It is essential that all professionals who come into contact with children are alert to the possibility of abuse play a role in problems presented by a boy and his family.

Table 3 Comparison of characteristics of children with absence persistent school and school refusal

School refusal

Absenteeism

The absence of school parents know

The absence of hidden school parent

Spend the day at home alone or with parents

May days go away with peers

Peak incidence at age 11

Increase with age

The fear of school or separation anxiety

No emotional

All classes

The increase in lower social classes

No increase in parental marital discord

Dysfunctional family

Overprotective parents

Harsh parenting

  

The incidence of abuse is difficult to measure since most cases go unreported, and varies from a definition of what constitutes abuse. The official figures of reported cases of maltreatment have increased in recent years, although this may be due to more information rather than a true increase in the abuse. A British study found that 12% of women and 8% of men had some kind of sexual abuse before the age of 16.

There are many contributing factors in the abuse of children. Some children are more vulnerable than others, for example those who are not allowed, an early separation from the mother, are physically or mentally disabled or some features temperamental make them difficult to handle. Some parents are more likely to be abusive, particularly those who have been abused as children living in bad circumstances socioeconomic and unrealistic styles of disciplining their children.

The most common form of sexual abuse is the father-daughter incest. Sexually abused children may present a sudden change in social behavior or academic performance or behavior problems. Some involved in sex play repetitive and are sexually precocious. It is important to give these children an opportunity to disclose their abuse, but great care must be taken to not increase their trauma. Social services should be informed disclosure sexual abuse by a child and instigating proceedings for child care. The emotional effects of child sexual abuse can be treated in individual psychotherapy with the child. Teens and adults can also be offered group therapy has the advantage of reducing the sense of isolation and allow the development of confidence and self esteem. A third of sexually abused children have no long term negative effects, the rest are prone to depression, low self-esteem, sexual problems, and have a tendency the re-victimization in adulthood.

Elimination Disorders

Enuresis

Bedwetting is the involuntary bladder emptying occur after the age of five years in the absence of an organic cause. Bed-wetting (nocturnal enuresis) is common, occurring 10% 5 years old, 5% of young people aged 10 years and 1% of 15 year olds. Daytime enuresis is less common. Enuresis is considered as principal, if there has been no previous period of bladder control, and secondary if it follows a period of continence. It is twice as common in children in girls, and are mostly believed to be due to delayed neurological maturation that simply correcting over time. There is often a positive family history of the same problem. Secondary enuresis can occur as a feature of regressive behavior in times of stress. Treatment consists of exclusion of a case physics, especially urinary tract infection, reassure parents and encourage them to handle the problem calmly and smoothly. The establishment of a behavioral program simple, like a map of the stars or the pad and bell can be used.

  

Encopresis

Encopresis is inappropriate defecation despite having normal bowel control. Most children are continent of feces by the age of 3 years. At 8 years, 2% of males and 1% of girls suffer from encopresis. This may be due to inadequate toilet training or have a psychological cause behavior that represent the child's feelings of anger or regression at a time of stress. Constipation with overflow incontinence is the primary diagnosis differential should be excluded.

Adolescence

Teenagers have social and emotional problems difficult to treat. For example, often conflicts over the degree of independence they want and are allowed to have their parents. The peer group becomes very important and influential, and can provide a valuable support for people to try new things away from family. They can also cause great anxiety for the rejection of the group, and may encourage criminal behavior. Development sexual intercourse is another potential source of confusion, anxiety and conflict.

The pattern of psychiatric disorders change as children become adolescents. There is a marked increase in major depressive disorder, especially in girls, and schizophrenia is much more common in late adolescence. Alcohol problems and drug abuse and eating disorders tend to emerge at this time. developmental disorders usually been resolved.

Reference:

1. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006

2. Smith G et al. Key topics in psychiatry. Bios Scientific Publisher Limited, 1996.

3. Boyle D, S Davies. Psychiatry, 2002 Mosby intensive

About the Author

Prof. Saoud Al Mualla (M.B, MSC, M.D, Dip, MRCPsych)

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